인지부하이론CLT 관점에서 의학교육과정 디자인 (Med Teach, 2016)

인지부하이론CLT 관점에서 의학교육과정 디자인 (Med Teach, 2016)

Twelve tips for medical curriculum design from a cognitive load theory perspective

JIMMIE LEPPINK1 & ROBBERT DUVIVIER2

1Maastricht University, the Netherlands, 2University of Newcastle, Australia

Introduction

본질적으로, CLT는 학습과제로 인해서 생기는 처리부담processing demands이 학습자가 가진 인지시스템의 처리능력processing capacity를 넘어설 때 생길 수 있는 잠재적 문제를 다루거나, 학습자의 인지적 자원이 최적화되지 못한 상태로 배분될 경우에 생길 수 있는 문제를 다룬다. 이는 선생과 학생 모두에게 문제가 되는데, 왜냐하면 의학에서 의미있는 학습이 발생하려면 본질적으로 제한된 인지시스템을 사용하여 엄청난 양의 인지적 프로세싱을 해야 하기 때문이다.

In essence, cognitive load theory deals with the potential problem that the processing demands evoked by learning tasks as complex as those in medical training may exceed the processing capacity of the learner’s cognitive system(i.e. they cause overload) or that the learner’s cognitive resources are allocated in a suboptimal manner. This is a challenge for both teachers and students, as meaningful learning in medicine often requires substantial cognitive processing using a cognitive system that is inherently limited

과제충실도, 과제복잡도, 교육적지원

Task fidelity, task complexity, and instructional support as core issues

These three issues can be conceived as three dimensions of a cube, as depicted in Figure 1.

Figure 1. A holistic model for how to integrate a competency into a medical curriculum (Leppink & Van den Heuvel 2015) applied to learning how to make a (particular type of) diagnosis:

(1) simple textual diagnoses with and then without instructional support;

(2) more complex textual diagnoses with and then without instructional support;

(3) simple diagnoses in a simulated environment with and without instructional support;

(4) more complex diagnoses in a simulated environment with and without instructional support;

(5) simple diagnoses in a real patient environment; and

(6) more complex diagnoses in a real patient environment.

첫 번째 이슈인 과제충실도는 다음을 포함함. (교과서와 다른 문헌, 모의환자, 실제환자)

The first issue, task fidelity, includes initial learning from textbooks and other literature, and advanced learning with simulated patients and eventually real patients.

 

두 번째 이슈인 과제복잡도는 학습과제의 난이도를 말함 (짧은 시간에 처리해야 하거나, 익숙하지 않거나, 새로운 정보가 많거나 등)

The second issue, task complexity, pertains to the difficulty of a learning task or activity. For example, a task becomes more complex when it has a shorter duration, it is unfamiliar to the learner, or includes a large amount of new information.

 

세 번째 이슈인 교육적지지는 테크놀로지 활용, 교수학습자원의 선택 등을 포함하며, 완전히 다 가공worked된 사례부터 자율적autonomous인 과제수행까지를 포함한다.

Finally, the third or instructional support issue includes the use of technology, and the selection of learning and teaching resources. It extends all the way from fully worked examples to autonomous task performance.

 

 

학습을 개별화하기 위한 역량의 활용

Using competencies to individualize learning

큐브 모델을 적용하여 학습경험을 개별화할 수 있으며, 학생들이 서로 다른 속도로 서로 다른 역량을 개발하게 할 수 있다.

Applying the cube model allows for individualiz- ing the learning experience, and enables students to move through different competencies at different paces.

예를 들어 당뇨병 환자 관리에 대해 배운다고 할 때...

 An example might help to illustrate this further. In learning about the manage-ment options for diabetes,

• 초보자에게는...
  the most useful technique for novice learners might include an overview of the various strategies and worked examples with explanation on clinical decision-making rather than asking students to solve a clinical problem and search for solutions by themselves.

• 전문성이 향상될수록...
  As expertise increases, one might present cases in a smaller group and encourage learners to present their suggested treatment plan without any kind of template. 

또한, 역량 발달은 하나가 다 발달하고 다음 것이 이뤄지는 것이 아니라, 학생은 다양한 역량 향상을 동시에 받게receive된다. 

Besides, competency development is typically not a process of developing one after another; students receive training in a variety of competencies at the same time.

12팁

Twelve tips

어떤 역량이든 HS-LC-LF에서 시작해서 LS-HC-HF로 가야 한다.

Whichever competency we are considering we have to work from a high-support low- complexity low-fidelity starting point to clearly defined end terms presenting an ability to function under low-support high- complexity high-fidelity circumstances.

과제충실도

Task fidelity

진단을 내리는 방법을 배우는 과정은 다음과 같다.

Learning how to make a particular type of diagnosis can be practiced

• 처음엔 텍스트로 first by reviewing textual descriptions,

• 컴퓨터 SP혹은 동료끼리 환자역할극으로 subsequently through practice with computer-simulated patients and/or patients role-played by peers,

• 전문 배우 SP로 next through simulated patients played by more professional actors, and

• 실제 환자 finally with real patients in an internship (Van Merrie¨nboer & Sweller 2010).

Medical competencies and topics as paralleled cubes (Leppink & Van den Heuvel 2015) in a coherent program. Figure 2.

과제 충실도 수준을 정하라

Ti p 1 Determine the number of fidelity levels

 

로지스틱스 요인이 제약을 가할 수 있다. 그렇지만 literature에서 실제 환자로 부드럽게 넘어가도록 최소한 한 가지 유형의 시뮬레이션은 있어야 한다.

Besides, logistic factors may put some constraints on for instance how many and which types of simulated patients are feasible. However, having at least one type of simulation appears necessary for a friendly transition from literature to real patients.

과제 충실도를 점진적으로 높이라

Ti p 2 Gradually increase fidelity

너무 초반부터 고충실도로 하면 학생을 두 가지 측면에서 과부하시킬 수 있다.

Starting in a high-fidelity environment too early may overload students in two ways,

첫째, HiFi환경은 너무 다양한 요소들이 있으나, 학생들은 그 요소들에 친숙하지 않아서 학생의 작업기억이 과부하를 겪는다. 둘째로, HiFi상황에서는 감정적반응emotions가 촉발되어 불필요한 작업기억의 부하를 일으키고, 이러한 감정이 bias를 자극하여 학습을 저해할 수도 있고, 학생은 진단에 필요한 프로세스보다 그러한 감정을 일으킨 사건에 초점을 둘 수도 있다. 따라서 충실도는 점진적으로 높아져야 함.

Firstly, high-fidelity environments may com- prise so many elements students are still unfamiliar with that their working memories are simply overloaded. Secondly, emotions evoked in higher- fidelity environments may certainly at first contribute to redundant working memory load and as such inhibit learning if these emotions stimulate bias (Kahneman 2011) or result in having students focus on the events that caused these emotions rather than on the process of coming to a diagnosis itself (Fraser, et al. 2012, 2014). It is therefore important that fidelity is increased gradually.

충실도를 높이는 과정

increasing fidelity by

• 문서로 introducing students to paper-based cases first (low fidelity), before

• 시나리오나 SP로 exposing them to scenarios with a simulated patient (medium fidelity) or

• 병동에서 실제 환자로 an immersive experience on the psychi- atric ward talking to real patients (high fidelity).

훈련자와 학생 간 지속적인 대화

Ti p 3 Stimulate an ongoing dialogue between trainer and student

어떤 학생은 HiFi에 더 빨리 준비를 갖출 수도 있음.

some students may be ready for a higher level of fidelity sooner than other students will. Making appropriate decisions with regard to which level of fidelity is appropriate for a given student requires an ongoing dialogue between trainer and trainee.

HiFi로 가려면 적절한 교육적지지가 필요함.

Ti p 4 Moving to higher fidelity requires appropriate instructional support

1~3번 팁은 경험이 없는 학생을 HiFi에 노출시키는 것이 나쁘다고 말하는 것이 아니다. 다만 우리는 학생의 zone of proximal development를 신경써야 하고, 학생이 자율적으로 수행할 수 있는 것이 무엇인지, 학생이 전문가의 도움을 받거나 다른 capable한 동료들과 협력하여 어디까지 배울 수 있는지를 신경써야 한다.

Tips 1–3 should not be interpreted as a statement that exposing inexperienced students to higher-fidelity contexts is necessarily a bad thing. However, we must be aware of students’ zone of proximal development (Vygotsky 1978) or the distance between what a given student can perform autonomously and what this student could learn with the help from an expert or in collaboration with more capable peers.

 

과제복잡도

Task complexity

 

통합된 신체진찰은 일련의 움직임을 순서에 맞게 따라하는 것보다 복잡한 것이다. 

Likewise, an integrated physical examination is of a higher level of complexity than doing a series of movements in the right sequence.

복잡도의 수준을 정하라

Ti p 5 Determine the number of complexity levels

복잡도를 differentiate하기 실패하면 일부 학생을 under-load하고 일부는 overload하게된다. 

Failing to differ- entiate in complexity, we may under-load some students (Young & Stanton 2002) and overload others (Kalyuga & Hanham 2011).

복잡도를 점진적으로 높여라

Ti p 6 Gradually increase complexity

학생이 advance할수록 더 높은 복잡도를 다룰 수 있게 된다. under- 든 over-든 좋지 않다. 높이는 과정은...

The more a student advances, the more complexity this student can handle. To neither under-load nor overload the student, we should strive for a gradual increase in task complexity (Van Merrie¨nboer & Sweller 2010; Leppink & Van den Heuvel 2015). An example of this gradual increase could be

• 증상을 비전형적으로, 진단을 덜 분명하게 from problem-based learning whereby paper cases progress from simple to more complex by making the presenting symptoms atypical and the diagnosis less clear.

• 환자를 복잡하게 complex patients (e.g. higher acuity, more comorbidities)

• 상호작용하여 관여하는 요소를 다양하게 number of interacting elements (time-pressure, unfamiliarity, large amounts of information)

자기조절을 자극하라

Ti p 7 Stimulate self-regulation

SRL은 두 가지 핵심 프로세스가 있다. 모니터링과 통제.

Self-regulated learning thrives on two key processes: monitoring and control (Nelson & Narens 1990; Zimmerman & Schunk 2001).

• 모니터링: 학습자가 자신의 인지에 대해서 생각하는 것
  The term monitoring refers to the thoughts learners have about their cognition, whereas

• 통제: 이러한 메타인지적 사고가 학습자가 적응적행동adapting behavior의 관점에서 어떻게 반응할지를 trigger하는 것. 그 다음에 어떤 학습활동을 할지 선택하는 것, 어떤 과제복잡도를 편한하게 느낄지 정하는 것 등등.
  the term control is used to refer how these meta-cognitive thoughts trigger responses on the part of the learner in terms of adapting behavior. Choosing subsequent learning activities or indicating what level of complexity one could feel comfortable with are examples of the latter.

HC로 가려면 적절한 IS가 필요하다

Ti p 8 Moving to higher complexity requires appropriate instructional support

As for fidelity, we must keep students’ zone of proximal development in mind.

교육적 지지

Instructional support

초심 학습자의 불필요한 인지부하를 줄이는 방법들

The use of

• 가공된 사례 worked examples,

• 완료과제 completion tasks,

• 비-특이적 목표 non-specific goals (e.g. ‘‘find as many etiological explanations for these symptoms as you can’’), and

• 다양한 sources들 사이에서 집중력을 분할split하지 않아도 되게 하는 프리젠테이션 presentations that avoid learners having to split their attention between multiple sources or having to process information through a suboptimal modality (e.g. having to process information verbally that actually ought to be presented verbally)

...constitute well-known tools to redundant reduce cognitive load among novice learners (Sweller et al. 1998; Van Merrie¨nboer & Sweller 2010).

지지 수준을 정하라

Ti p 9 Determine the number of support levels

초심자에게 redundant한 인지부하를 줄이기 위해 개발된 도구가 오히려 guidance없이 길을 찾아갈 수 있는 학습자에게는 redundant한 인지부하를 주게 된다.

That is, tools aimed at reducing redundant cognitive load among novices tend to contribute to redundant cognitive load among learners who are able to find their way without that guidance (Kalyuga et al. 2001, 2003).

서서히 지지 수준을 낮추라

Ti p 10 Gradually decrease support

 

어떻게 하나

When learning how to do this for

• 처음에는 스텝-바이-스텝 the first time, provide students with step-by-step instructions and feedback,

• 그 다음에는 피드백만 줌 then only provide them with feedback, and

• 최종적으로는 피드백도 안 줌 finally provide no feedback at all.

 

각 복잡도와 충실도단계마다 이러한 점진적 지지수준을 낮추는 원칙이 적용되어야 한다.

This principle of gradually fading support is to be repeated at subsequent complexity and fidelity levels.

 

다양한 교육적지지 수준에서 practice해보게 함.

Ti p 11 Enable practice at different levels of support

 

학습자의 모니터링과 통제를 support하는 방법은 적절한 타이밍에 형성평가를 하는 것이다.

One way to support monitoring and control on the part of the learner (i.e. self-regulated learning) is through well-timed formative assessments,

형성평가는 반드시 autonomous한 과제수행에서만 해야 하는 것은 아니며, 가공된worked 예시에 대한 self-explanation 또는 수술의 특정 부분만을 수행하게 하는 것도 형성평가를 위한 완벽한 순간이다. 

Formative tests can pertain but are not limited to autonomous task performance; self-explanation of worked examples or for instance performing only a specific part of a surgery (Van Merrie¨nboer & Sweller, 2010) can provide excellent moments for formative assessment.

 

인지부하 수준을 계속 track하라.

Ti p 12 Keep track of cognitive load

학생의 발달과정에 따라 계속 추적해야 함. 어떻게 CL을 측정할지는 학자마다 의견이 다름 

teachers and curriculum developers should consider keeping track of cognitive load experienced by their students along the way (Leppink & Van den Heuvel 2015; Leppink et al. 2015). The question of how to measure cognitive load has however proven difficult for researchers.

• Further, the Paas Cognitive Load Scale is a single-item measure whereby learners are asked to rate the perceived intensity of their mental effort at a given task or activity along a 9-point scale (1¼very, very- low mental effort; 9 ¼very, very-high mental effort) (Paas 1992).

• Another frequently used instrument is the NASA Task Load index, which uses a visual analogue scale to indicate the perceived level on six subscales: mental demand; physical demand, temporal demand; performance; effort; and frustration (Hart & Staveland 1988).

Conclusions

• 과제충실도Task fidelity:

• to avoid cognitive and/or emotional over- load, we move up from literature through (different types of) simulated patients to real patients; starting at or moving to a higher level of fidelity should be accom- panied by sufficient instructional support.   

• 과제복잡도Task complexity:

• to avoid cognitive overload, we should gradually increase learning task complexity and provide sufficient instructional support when moving to more complex tasks.   

• 교육적지지Instructional support:

• for a given fidelity and complexity, instructional support should be faded gradually from tasks worked examples through completion tasks to performed autonomously.

Leppink J, Van den Heuvel A. 2015. The evolution of cognitive load theory and its application to medical education. Perspect Med Educ 4: 119–127.

Van Merrie¨nboer JJG, Sweller J. 2010. Cognitive load theory in health professional education: Design principles and strategies. Med Educ 44: 85–93.

Young JQ, Sewell JL. Applying cognitive load theory to medical education: Construct and measurement challenges. Perspect Med Educ 4:107–109.

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Med Teach. 2016 Jul;38(7):669-74. doi: 10.3109/0142159X.2015.1132829. Epub 2016 Jan 25.

Twelve tips for medical curriculum design from a cognitive load theory perspective.

Leppink J1, Duvivier R2.

Author information

• 1a Maastricht University , the Netherlands .
• 2b University of Newcastle , Australia.

Abstract

During their course, medical students have to become proficient in a variety of competencies. For each of these competencies, educational design can use cognitive load theory to consider three dimensions: task fidelity: from literature (lowest) through simulated patients (medium) to real patients (highest); task complexity: the number of information elements in a learning task; and instructional support: from worked examples (highest) through completion tasks (medium) to autonomous task performance (lowest). One should integrate any competency into a medical curriculum such that training in that competency facilitates the students' journey that starts from high instructional support on low-complexity low-fidelity learning tasks all the way to high-complexity tasks in high-fidelity environments carried out autonomously. This article presents twelve tips on using cognitive load theory or, more specifically, a set of four tips for each of task fidelity, task complexity, and instructional support, to achieve that aim.

PMID:

 

26806279

 

DOI:

 

10.3109/0142159X.2015.1132829

[PubMed - in process]